Provider Demographics
NPI:1053474437
Name:KETSELA, NARDOS HLAWE (DDS)
Entity Type:Individual
Prefix:DR
First Name:NARDOS
Middle Name:HLAWE
Last Name:KETSELA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 EAST WEST HIGHWAY
Mailing Address - Street 2:SUITE 208
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814
Mailing Address - Country:US
Mailing Address - Phone:301-656-7872
Mailing Address - Fax:301-656-7874
Practice Address - Street 1:4405 EAST WEST HIGHWAY
Practice Address - Street 2:SUITE 208
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814
Practice Address - Country:US
Practice Address - Phone:301-656-7872
Practice Address - Fax:301-656-7874
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12655122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist